This is a guide to Adult Hepatitis B Screening, treatment and monitoring.
See Pregnancy Page for Hep B infection in pregnancy

Screening

• Transmission: if infected perinatally or as a young child, 90% chance of chronic infection. If infected as an adult, 5% of chronic infection.
• Who to Test: CDC recommends testing all patients from Asia, Africa, Middle East, Eastern Europe, Amazon Basin, Guatemala, Caribbean for HBV. We should also test all family members - parents, children, and sexual partners of HBV infected pts, as its primarily perinatally and sexually transmitted,
• Order a chronic hep panel + Hep B sAb, checking a Hepatitis B sAb at the same time will help with recommending vaccination if sAg and sAb negative.

Diagnosis:

Diagnosis	HepBsAg	HepBcAb	IgM HepBcAb	HepBsAb	Notes
Non-Immune, Non-exposed	Negative	Negative		Negative	Offer Immunization
Immune due to Natural Infection	Negative	Positive		Positive	No IZ necessry
Immune due to Vaccination	Negative	Negative		Positive	No IZ necessary
Acute Infection	Positive	Positive	Positive	Negative	Risk of Chronic Infection
Chronic Infection	Positive	Positive	Negative	Negative	See below for work-up
Resolved Infection (Most Common)	Negative	Positive		Negative	Possibly resolving acute infection or low level chronic infection. Most often false positive OR prior infection w/ HepB SAb levels too low to detect. Likely only 10% have occult (active) hepatitis. But Hep B is covalently bound to DNA, and all previously infected patients can reactivate with chemotherapy or w/ some of the immunotherapy used for autoimmune disease.

Initial Work-up (for Chronic Infection):

All patients with a positive hepatitis B surface antigen should be initially tested for:

• Hepatitis B eAb
• Hepatitis B eAg
• Hepatitis B Viral Load
• Liver Function Panel
• CBC
• PT/INR
• HIV
• AFP
• Ultrasound

Who to refer:

• Signs of liver inflammation elevated AST/ALT or Platelets <140
• Splenomegaly on Ultrasound
• Hep B DNA level > 2000.
• Consider referral for biopsy at time of referral (Please consult)

Routine Monitoring:

Regardless of whether on treatment, patients can change over time including their level of inflammation, viral loads, and fibrosis. Overtime, the major risk of Hepatitis B is cirrhosis and hepatocellular carcinoma (HCC). Patients with inactive disease can reactivate anytime -- many patients periodically go in and out of inactive phases. For this reason, as long as someone is Hep B sAG +, lifelong monitoring is recommended.

• AST/ALT every 3 months for 1-2 years then every 6-12 months if normal.
• Hepatitis B Viral Load every 3 months for 1-2 years then every 6-12 months if <2000.
• Hepatocellular Carcinoma: Screen with US every 6-12 mo +/- AFP q6 mo. Only screen high risk populations:
  • Asian, Men >40 and Women >50
  • African >20 years old
  • Cirrhosis
  • FMHx of HCC
  • All chronic hep B >40 years with persistent ALT elevations and/or viral load >2000

Summary of Stages:

Stages of Hepatitis B are useful to help determine treatment and monitoring.

	Hepatitis B sAg	ALT	Hepatitis B eAb	Hepatitis B eAg	HBV DNA	Biopsy	Risk of Cirrhosis/HCC	Treatment
Immune Tolerant Phase	Positive	Normal	Negative	Positive	High >200,000	Minimal Fibrosis	Low	Not Recommended
Immune Active Phase	Positive	Elevated/ Fluctuating	Negative	Positive	High >200,000	Active Inflammation	High (Men >40, Women >50)	Consider if Age >40, DNA >20k, ALT persistently 2x normal, fibrosis on bx or high risk
Non-replicative/Inactive "Carrier" Phase	Positive	Normal	Positive	Negative	Low <2000	Minimal Fibrosis	Low	ALT 2x ULN, DNA >20k, bx if DNA >2000, treat fibrosis.

Who benefits from Treatment:

Benefit for Hepatitis B treatment depends on the severity of liver disease and the risk of cirrhosis and hepatocellular carcinoma (HCC).

1. HepBeAg Positive: ALT 2x ULN and viral load >20,000. This should be persistent over 3-6 months. Goal of treatment is conversion to eAb positive and eAg negative status. Discontinue treatment 6 months after conversion.
2. HepBeAg Negative: ALT 2x ULN and viral load >20,000. Consider treatment after biopsy if ALT 1-2x ULN and viral load 2000-20,000 or if biopsy shows fibrosis (stage 2 or greater).
3. Cirrhosis:
   • Decompensated: Treat patients immediately with progressively worsening liver disease and signs of decompensation (ascites, encephalopathy, portal hypertension, or hemorrhage).
   • Compensated: Treat If viral load >2000. Patients with compensated cirrhosis are at increased risk of HCC and treatment can improve their Child-Pugh score with treatment.
4. Immunosuppressive therapy: Chemotherapy or other immunosuppresants (i.e. biologic agents for autoimmune disorders, etc) can cause reactivation of hepatitis B activty in patients with minimal hepatitis B activity. Regardless of ALT and viral load, start treatment before immunosuppressive therapy.

Who may not benefit from treatment:

1. Young Patients <40 years old
2. Immune tolerant phase with absence of hepatic inflammation (i.e. normal ALT and/or no fibrosis on biopsy) even if they have high DNA levels.
3. Non-replicative Phase with low DNA levels and normal ALT.
4. Monitoring reccomendations for patients not on treatment

First-Line Treatment Options

1. Entecavir
2. Tenofivir
3. Peginterferon alpha-2a: Contraindicated in cirrhosis, pregnancy, immunosuppressive therapy

Stopping Treatment:

1. For eAg positive patients, goal of treatment is to achieve eAg negative/eAb positive status. If this is achieved, treatment can be stopped after 6-12 months. Unfortunately, eAg seroconversion only occurs in about 25% of pts.
2. For eAg negative patients, no specific end point is available to stop treatment. Stopping treatment usually results in rebound of viral load and hepatic inflammation. As a result, life long treatment in recommended.

References:

Management of Chronic Hepatitis B - Hargrave - 2011 - 1.pdf
Sorrell et al. "National Institutes of Health Consensus Development Conference Statement: Management of Hepatitis B." Ann Intern Med. 2009; 150: 104-110
Kowdley, Kris. "Understanding and Implementing the AASLD's HBV Practice Guidelines and other recent Guidelines and Recommendations on the Diagnosis Managment and Treatment of Hepatitis B." Clinical Care Options www.clinicaloptions.com/hepatitis Accessed July 17, 2011.
HepBMoms.org - an online tool for patients and providers about perinatal Hep B.